Senate Committee on Indian Affairs in re SDPI Reauthorization

The Senate Committee on Indian Affairs

Oversight Hearing on the Special Diabetes Program for Indians

March 29, 2017

Testimony Submitted by National Council of Urban Indian Health

Ms. Ashley Tuomi
National President

On behalf of the National Council of Urban Indian Health (NCUIH), which represents urban Indian health care programs (UIHPs) across the nation that provide high-quality, culturally-competent care to urban Indians, who constitute more than 70% of all American Indians / Alaska Natives (AI / AN), I, Ashley Tuomi, NCUIH’s President, submit this testimony for the record in relation to the March 29, 2017, oversight hearing held by the Senate Committee on Indian Affairs on the Special Diabetes Program for Indians (SDPI).

I thank Chairman Hoeven for holding this hearing as well as his interest in SDPI and Ranking Member Udall for his recent introduction of the Special Diabetes Program for Indians Reauthorization Act of 2017 (S. 747), which NCUIH strongly supports. S. 747 would reauthorize SDPI for seven years—from fiscal year 2018 through fiscal year 2024—at no increase in cost other than taking into account health care inflation. NCUIH urges Senators to cosponsor this important legislation in order to show the support necessary to secure SDPI’s timely reauthorization.

It is imperative that SDPI be reauthorized before its expiration on September 30. Grants to health care providers in Indian Country made pursuant to SDPI have been instrumental in the marked reduction in the incidence rate of diabetes— and the related savings to Medicare, the Indian Health Service (IHS), and third party providers.

At NCUIH’s recent Washington Summit, timely reauthorization of SDPI was one of our organization’s top legislative priorities, even with a broad and comprehensive legislative agenda. The failure to reauthorize this program would severely undermine the promising progress UIHPs and Indian Country have made against diabetes. UIHPs are proud of their role in the fight against diabetes,—Out of the 301 SDPI grants, 30 grants (out of 43 urban programs) went to UIHPs, or 6.65% of the $136,074,763 SDPI funds awarded nationally.

The Committee is very familiar with the grim statistics of the toll that diabetes inflicts on Indian Country. AI / AN adults are 2.3 times more likely to have diabetes compared with non-Hispanic whites and the death rate due to diabetes for AI / AN is 1.6 times higher than the general U.S. population. And the costs in dollars are also extraordinary—in 2012 alone 11% of AI / AN with diabetes accounted for 37% of all IHS adult treatment costs.

However, the Committee also knows that SDPI achieves outstanding results and that the program saves significant money in the long run. SDPI supports over 330 diabetes treatment and prevention programs in 35 states, which have led to significant advances in diabetes education, prevention, and treatment. In 2000- 2011, the incidence rate of End-Stage Renal Disease (ESRD) in AI / AN people with diabetes declined by 43%--a greater decline than any other racial or ethnic group. ESRD is the largest cost-driver of Medicare costs. Reduction in the incidence rate translates into significant cost savings for Medicare, third party payers, as well as IHS.

Let me tell the Committee how seven UIHPs have used SDPI funds to provide valuable services which have transformed and saved their patients’ lives.

First, we can start in the northeast to Detroit, Michigan where my own program, American Indian Health and Family Services, resides. Last year we attempted to refer clients for services outside of the agency that we sponsored with SDPI funds for diabetic testing, but we found that program unsuccessful, as patients were unlikely to follow-up with the referral. During this fiscal year we changed course and decided with SDPI funds we would purchase a retinal camera that now allows us to do undialated eye exams in the clinic. Now that we have our own equipment in house, we are able to catch the patients right when they enter our facility and there has been an immediately increase in retinal eye exams. We are catching diabetes as soon as it enters the door, thanks to SDPI funding.

Then we can travel to the Great Plains, at the South Dakota Urban Indian Health (SDUIH), which serves both Pierre and Sioux Falls with full-time primary and behavioral health clinics.

SDUIH has participated in the SDPI program for fifteen years. Throughout this time, SDUIH, with its accreditation from the American Diabetes Association, has provided direct diabetes patient education, prevention and treatment services that benefits those who have diabetes as well as those who are at high- risk of getting diabetes.

SDPI funds have made it possible for SDUIH to add physical fitness centers located on-site within the clinic facility that offer new and state-of-the-art equipment. SDUIH has also added a fully operational teaching kitchen that allows patients to participate in cooking classes and learn how to improve their diets.

SDPI funds support the program’s grocery store tours during which patients are accompanied by a care manager who teaches them how to shop for healthier and more nutritious food. Funds have also been used to purchase the lab equipment necessary for operating a high-level diabetes program, including Piccolo machines, DCA Vantage Analyzers, and HemoCue testing devices.

SDPI funds allow SDUIH to employ highly-qualified staff to prevent and treat diabetes, including certified educators, registered dieticians, licensed nutritionists, fitness / yoga class instructors, and child care providers.

Ms. Donna LC Keeler, the SDUIH Executive Director, reports that SDPI funds have allowed her program to provide a wide array of services to the diabetic patients serviced by SDUIH. According to the most recent Indian Health Service Annual Diabetes Audit, 59% of the program’s patients have had diabetes less than 20 years and 79% are diagnosed with comorbidity of hypertension which demonstrates the need of continued funding and services. Positive results from SDPI for the SDUIH program include 55% of their patients having blood sugar (A1c) control of 7.9 or less and 77% having blood pressure of 140/90 or less, so progress is being made but there still is so much left to do.

Thanks to SDUIH’s use of SDPI funds, 100% of all diabetic patients are screened for tobacco use; 97% have comprehensive foot exams; 77% have retinal imaging eye exams; 71% have annual dental exams; 99% have diabetes education; 97% have physical activity education; 85% have flu / pneumococcal vaccines; 73% have hepatitis B immunizations; and 100% of diabetic patients are screened for depression.

Ms. Keeler sums up the fight being waged by SDUIH against diabetes: “While, clearly, SDPI has been a success—lives of patients have been saved and their health status has been improved—much work remains to be done. Without SDPI funds, SDUIH would not be able to retain the dedicated diabetes staff that have accomplished so much for so many patients. It is critical to continue funding in order to fight against diabetes in Indian County.”i

Let’s shift our focus to Tulsa, Oklahoma, where the Indian community is served by the Indian Health Care Resource Center of Tulsa (IHCRC), a comprehensive clinic which cares for almost 12,000 patients annually. Accredited by the American Association of Diabetes Educators, IHCRC has used SDPI funds for almost 20 years to offer a variety of programming, including diabetes case management, fitness and exercise, nutrition counseling, and diabetes education.

Ms. Carmelita Skeeter, the program’s chief executive officer, reports that during FY2016 alone, IHCRC’s diabetes program served 1,410 duplicated patients in the clinic for diabetes case management (63), diabetes education (649), diet management (604), and exercise / fitness education (94). Specific program goals include glycemic control, nutrition education, and physical activity education. IHCRC’s public health nurse, originally funded through the Healthy Heart program and now through SDPI, coordinates community efforts and the integration of diabetes case management into primary care, especially for repeatedly non-compliant patients.

A chart audit of 881 patients with diabetes revealed that 77% had known hypertension and 72% had a Body Mass Index (BMI) of 30.00 or above (obesity). Based on BMI, one-third of IHCRC’s 3,700 patients under the age of 18 are overweight or obese. With this information in mind, IHCRC knows that helping patients to develop a healthy lifestyle can also help to end the vicious cycle of this disease.

IHCRC’s diabetes programs have been enhanced in recent years to include prevention, especially for youth and families. Collaboration with the N7 Fund, Southern Plains Tribal Health Board, and an area funder have helped to further expand the programs.

Programs range from summer wellness camps to training teachers and youth workers to use physical activity in teaching. This teaching style has proven to activate the brain, improve on-task behavior during academic instruction time, and increase daily physical activity levels among children. The Sit Less, Move More, Learn Better program, attended by approximately 60 teachers and youth workers each year, has helped more than 70,000 youth across Oklahoma.

The youth fitness and diabetes prevention program includes Summer Wellness Camp, a youth run club (initially funded by the N7 Fund), youth fitness programs, and two annual Family, Fun and Fitness Days. Each year, more than 300 youth attend the camp which focuses on diabetes prevention, healthy lifestyles, leadership, team-building, cultural experiences, and problem-solving.

The annual family fun and fitness festival, attended by more than 450 people since inception, brings families together in an active environment. The day’s highlight is the One Mile Fun Run and Walk.

The program’s fight against diabetes has been further enhanced by engaging youth and families in a running club in which 25 youth and their family members participate. The club meets every Saturday morning to run together and participates in approximately six community runs during the year. During the winter group members work out at the YMCA and participate as a club in social activities and community service.

“No one could have ever anticipated the changes that occurred in the running club participants,” reports Ms. Skeeter. “Youth have become stronger and healthier. They have become socially connected with one another and with others they have met through community races. Families have begun running and working out together. Youth self-esteem has improved. Youth have learned to provide encouragement to others including their own family members. Community volunteers including members of American Electric Power’s Native American employee group have become extremely involved with the club.ii Overall, the diabetes education program has made significant strides in diabetes prevention for youth and families.”iii

Like Ms. Keeler, her counterpart in South Dakota, Ms. Skeeter is a passionate supporter of SDPI, having seen modest amounts of money turn around the lives of so many Tulsans in such meaningful ways, and she is also determined to see the program reauthorized.

Let’s take the I-44 west and learn how the Oklahoma City Indian Clinic (OKCIC) has used SDPI funds for 18 years to provide essential services to its 2,948 patients with diabetes, 2,994 patients with prediabetes, and 4,672 youth patients, out of an active patient clinic population of 18,077.

Beginning in 2001, reports Ms. Robyn Sunday-Allen, OKCIC’s chief executive officer, SDPI funds began paying for the program’s first Teaching Urbans Roads To Lifestyle & Exercise (TURTLE) Camp for children. This initial day camp for OKCIC youth was focused on diabetes prevention for children 12 to 16 years of age. Sessions on nutrition, exercise, diabetes education, drug and alcohol abuse, tobacco abuse have been held by OKCIC for the past 16 years.

SDPI funding has also allowed OKCIC to add a wellness center to the clinic’s campus. Patients are able to work out individually, participate in group activities or meet with a personal trainer / life coach. In fact, the wellness center has become the social community for OKCIC patients as they participate in group fitness classes, diabetes prevention / education meetings, cooking classes, and cultural activities.

Recognizing the importance of good nutrition, OKCIC began holding cooking demonstration classes in 2013, and SDPI funding helped to equip a kitchen. All patients and their families are welcome to learn from the registered dietitian / chef to see how to prepare healthy foods within a reasonable budget. Participation in the cooking classes has increased from 560 visits in 2013 to 1670 in 2016.

In addition, OKCIC provides annual back-to-school physicals, immunizations and screening at the program’s Children’s Health Fair. Through these screenings, youth at risk are referred to follow-up services where parents and their children receive education to make the necessary changes to develop healthy lifestyle habits. “SDPI funding,” reports Ms. Sunday-Allen, “allows OKCIC to go beyond being simply an ambulatory health care facility, which helps to endow our patients with the courage to move towards healthier lifestyles.”

OKCIC, thanks in large part to SDPI funds, provides disease prevention programming to AI / AN children in an effort to prevent Type 2 diabetes and related co-morbidities. These programs include weekly afterschool programs, school break programs and 1:1 nutrition and physical activity counseling. Afterschool programming includes boxing, adventure sports, running, golf, and tennis. School break programs include, in addition to TURTLE Camp: Kids in the Kitchen, swimming lessons, NYPD Camp (Native Youth Preventing Diabetes), jump rope camp, basketball camp, dance clinic, culture camp and NKOG Camp (Native Kids on the Go!).

All interventions assess children for weight status, acanthosis nigricans, blood pressure and obesity-causing behaviors such as sugar-sweetened beverage intake, fruit and vegetable intake, physical activity engagement and screen time. The OKCIC staff uses this information to create fun and effective nutrition- and physical activity-based activities that re-enforce the lifestyle modifications necessary to maintain a healthy weight and reduce the risk for Type 2 diabetes. Each disease prevention experience includes a nutrition and physical activity component.

Ms. Sunday-Allen reports that outcomes after post-programming demonstrate that the “patient population experienced a substantial decrease in BMI percentile, the pediatric gauge for weight. In fact, the average BMI percentile dipped less than the level used for overweight classification (80th percentile), which is an encouraging sign of positive disease prevention progress. The change in BMI percentile may be a result of the significant decrease in sugar- sweetened beverage consumption and a decrease in sedentary screen time usage. While time in physical activity did decrease, the average remains above the Center for Disease Control’s recommendation. These programs are made possible by SDPI funds for health educators, which include registered dietitians, physical activity specialists and support personnel as well as for venue rental, program supplies, and food.”iv

Ms. Sunday-Allen recognizes that OKCIC’s significant anti-diabetes effort would not have been possible without SDPI funds, and she strongly urges the Congress to reauthorize the program before the end of the fiscal year.v

Let’s finish our survey of how specific UIHPs are using SDPI funds by heading to the west coast. First, let’s hear from the Native American Rehabilitation Association of the Northwest (NARA), which serves eight locations in the Greater Portland Area. NARA focuses its diabetes efforts on screening, prevention, early diagnosis, and mitigating against complications caused by diabetes. Using SDPI funds since 1999, NARA has established a stable, cohesive, multi-disciplinary clinical group with more than 65 years of combined experience that serves over 500 people with diabetes and 1,000 patients with prediabetes.

NARA celebrated the success of its diabetes prevention program in 2016, receiving plaudits from lawmakers and public health experts alike. Since NARA first offered prevention classes in June 2006, the 133 graduates who completed the 20-week lifestyle balance curriculum--which includes weekly group meetings, tracking food intake, and increasing physical activity-- collectively lost 1,350 pounds and 213 inches from their waist. NARA reports that prevention program graduates eat less unhealthy food, and more fruits, vegetables, and whole grains. NARA staff continue to meet with graduates monthly and support them as they strive to change their lifestyles.

NARA sees cultural competency and community partnerships as keys to its success in its fight against diabetes, striving to achieve a visible presence at community gatherings, cultural activities and powwows, in order to provide diabetes education and outreach.

NARA partners with the Casey Eye Institute’s Outreach Team at Oregon Health Sciences University, which uses the team’s mobile eye van to provide free dilated eye exams and prescriptions for glasses twice a year to the program’s patients with diabetes. NARA also partners with the Mount Tabor podiatry office, which often treats the program’s uninsured patients free of charge.

NARA shares best practices with the Northwest Portland Area Indian Health Board and local tribal organizations as well as the American Diabetes Association.

And through a partnership with mental and behavioral consultants, almost forty patients with poorly controlled diabetes (i.e., A1C greater than 9.0%) have been screened using a culturally-specific trauma examination process. The results indicate a strong correlation between a history of personal, past and / or intergenerational trauma and poorly-controlled diabetes. When patients screen positive for trauma, the behavioral health consultant coordinates referrals to a mental health consultant.

NARA successfully uses Saturday diabetes clinics, which are the program’s convenient "one-stop-shop" clinic for people with diabetes to receive their annual diabetes "tune-up.” Services provided at these clinics are podiatry, nutrition and exercise counseling, foot and nail care education, immunizations, laboratory testing, medication adjustments, diabetes education, and digital retinal screening. In fact, the percentages of patients completing a foot exam (97% vs 80%), eye exam (78% vs 51%) and diabetes education (96% vs 84%) were higher for Saturday diabetes clinic participants than the general NARA diabetes patient population.

If the Congress fails to reauthorize SDPI, NARA would no longer be able to provide the Portland Indian community with the following services: diabetes screening; diabetes prevention; diabetes self-management education classes; nutrition and exercise counseling, podiatry services, retinal imaging services, and dilated eye exams for diabetics; and case-management for patients with prediabetes and diabetes.

Now, let’s head south to California, where the Indian Health Center of Santa Clara Valley (IHCSCV) has established a holistic anti-diabetes program for education, prevention, and treatment that is an example for the general population of northern California.

IHCSCV’s education effort is led by a registered nurse and it is further staffed with health educators, who provide one-on-one and group education about diabetes, teaching patients how to prevent the onset of the disease and mitigate against its complications—whether at the patient’s home, at the program’s wellness center, or at other health care facilities. Almost one-third of the budget for the wellness center has been paid for by SDPI funds.

IHCSCV’s diabetes program, which was originally funded by SDPI, works to prevent or delay the onset of diabetes through manageable lifestyle changes. Although the SDPI grant expired last year, IHCSCV continues its fight against diabetes because of its continued harshly disproportionate impact on the Indian community in Northern California.

IHCSCV’s primary care staff at the main facility as well as at three family practice clinics, and one pediatric clinic used SDPI funds to provide patients with the tools they need to manage their condition, including glucometers, test strips, lancets, blood sugar logs, pill cutters, diabetes socks, feet mirrors, and oral health supplies. Patients whose condition is more problematic benefit from intensive case-management.

IHCSCV’s anti-diabetes effort is impressive in its comprehensiveness. IHCSCV has a fitness center that is free for all patients and available to patients at all skill levels. Many fitness classes are designed for patients who are elderly or have limited mobility, including Zumba and chair exercise classes. IHCSCV’s fitness coordinator is also a personal trainer, who is able to offer one-on-one personal training to patients of all ages and skill levels.

IHCSCV helps its diabetes patients overcome transportation barriers imposed by limited mobility and social isolation. The program provides transportation for medical, dental, counseling, and specialty appointments, as well as to the wellness center and community events that are hosted for the Indian community by IHCSCV and its partners.

IHCSCV’s diabetes patients often have many health complications and are facing other obstacles to their health—including homelessness, mental disabilities, limited income, and lack of health insurance. IHCSCV’s case management team works closely with the patients and their primary care providers to coordinate the care within and outside of the program. The case management team arranges appointments with dentists, licensed clinical social workers, and psychiatrists at the program as well as with outside specialists like cardiologists, endocrinologists, nephrologists, and oncologists. In fact, some IHCSCV managers speak with their patients almost daily.

Like other UIHPs, IHCSCV believes it is imperative to reauthorize SDPI. Despite its accomplishments in the fight against diabetes, the program continues to treat new Indian patients with diabetes. Loss of SDPI funds would result in a significant decrease in access to transportation, which could mean that many patients would be less likely to receive the regular care necessary to control their diabetes. Loss of SDPI funds would also prevent IHCSCV from engaging in its aggressive, comprehensive case management or providing diabetes refreshers, which are two hour education classes specifically tailored for Indian patients with diabetes.

Finally, let’s head north, to the Seattle Indian Health Board (SIHB). Thanks to the SDPI funds, they have a diabetic team that provides a comprehensive case management team consisting of a nutritionist, RN, MA, case manager, and PharmD. This team has been able to provide robust case management services that supplement the care our patients receive from their primary care provider.

The services they provide because of the SDPI program include diabetes and lifestyle education, assistance developing and reaching self-care goals, support for well-being, referral assistance, etc. The program has also provided group education classes on topics including exercise, diet, and general diabetes education. SDPI funding has also provided onsite optometry and podiatry specialty services for our diabetic patients.

Without SDPI, SIHB would anticipate at least a 75% reduction in the diabetic case management services that they currently provide. They would also lose the ability to track and follow up with diabetic patients who were lost from care or have poor follow-up. This would inevitably lead to poorer outcomes for the patients and increased medical costs for the entire health system.

NCUIH appreciates the opportunity to testify about the challenging but promising work of UIHPs in educating against, preventing, and treating diabetes which have, literally, saved and transformed lives in Indian Country. So much of that work would not have been possible without SDPI, which is why NCUIH strongly urges the Committee to ensure that the program continues without any interruption. Quite simply, SDPI must be reauthorized if Indian Country is to educate against, treat, and prevent the terrible scourge that is diabetes. Thank you for your consideration. Please contact NCUIH if you have any questions about our testimony.

i Here is an appreciative note Ms. Keeler received from one SDUIH patient about the program’s SDPI-funded diabetes treatment:

I just wanted to touch base with you and thank you for getting me involved in the program. If you ever had any doubts about the importance of it, I want to let you know I did go to my eye exam and they did find I had cataracts due to my diabetes. So this program, in the long run will have saved my life. I just wanted to let you know what they found. This has certainly, with no pun intended, opened my eyes to my responsibility in regards to my diabetes. Again-just a call to say thank you. Also, my children both have pre-diabetes and would like them to start coming to your facility. But anyway, this work is so important and thank you again!”

ii Sally is a 12-year-old participant in IHCRC’s Running Strong youth run club. A wonderful but unexpected outcome of the club is that many parents are inspired to participate with their children, and Sally’s mother registered to run alongside her daughter in a 5K.

I did my first 5K!!! I was not in the front of the pack but I wasn’t the last one either so I will take that as a win!!! I did it for my amazing daughter Sally who of course kicked my butt. She did great in her first 5K also. I am so proud. Wished I could have seen her come over the finish line. I did meet some very sweet ladies that helped me along the way. And a huge thanks to Sally’s run club!!! You all are rock stars.

One week later, there was another 5K – this one in brutally cold weather. Sally’s mom commented:

Today I finished another 5K with the help of my amazing daughter. She ran back and got me and helped me finish strong. She is such an amazing kid. Although the running is hard I love that we are doing it together. Even if she kicks my butt (lol). It is something we can enjoy and push each other with. All of it wouldn’t be possible without her amazing run group and coach Jennie Howard. We could never thank you enough.”

iii Here is the success story of one family in which every member weighed in excess of 250 pounds when they began IHCRC’s program:

I wanted to let you know what a positive move this has been for our whole family. The first positive is our weight loss. Our oldest son lost 109 pounds during the past year. His younger brother only lost 17 pounds but his grades increased as his weight has decreased. I can’t thank you enough for the changes that you have brought to my family! I just can’t believe the positive outcome of exercise!

“We have stopped drinking sweet tea and we haven’t eliminated sweets but we only have them on special occasions. We have also tried to limit our bread / other sugar intake. A big deal for us was portion size, we seen nothing wrong with eating 2 or 3 plates. Now we try to only have 1. We work out at least 5 times a week. We try to go 7 days a week but sometimes other activities interfere (work / school). We also play volleyball and basketball.

“We are a healthy family and working towards improving that even more and we enjoy it!!! I began using my Facebook page as an exercise log to help keep me accountable. This in turn has encouraged many of my friends to begin walking or working out. I am motivating others and it feels awesome! I have people private message me about what they are trying to do because they don’t want to go public in case they fail, and I encourage them that a little exercise is better than none and there is no failing when you are doing something to move your body around.

“My husband was diagnosed borderline diabetic. Diabetes runs on his side of the family and he has seen all the struggles his dad has before he passed away from it. We are hoping that all of the things we have done will defeat that disease and break the cycle.”

iv Here are five testimonials from patients who have been treated for diabetes by OKCIC.

1.  GS, a proud “great great grandpa” and an OKCIC patient for more than 30 years, states:

“Different foot doctors all wanted to cut off my foot. I would take off my shoes and show them my foot and they all said if they didn’t take off my foot, they’d have to take off my leg up my knee”. I came to Oklahoma City Indian Clinic and saw the Wound Care Team. They said, `We can save that!’ Everyone was so positive here. OKCIC gave me support care, the podiatrist and other doctors have been a great help.”

 2  “Six years ago I was approached by a member of the Steps to Achieve Results (STAR) program in the Oklahoma City Indian Clinic wellness center. I was told about an upcoming Diabetes Alert Day…I was given an appointment with my provider and I found out I was pre-diabetic. I have seen diabetes at its worst. So, of course when I learned I was pre-diabetic, I wanted to learn as much as I could in order to keep from becoming diabetic. I did not want my children to see me like I saw my dad. I knew they would take care of me, but I did not want them to have to. I enrolled in the STAR program where I learned how to count my daily fat grams and calories. I also learned how to prepare my food differently. I learned how to lose 7% of my starting weight and how to keep it off by adding activity with my food choices. I learned a lot and after 16 weeks finished the program. After being in the program, I thought it would be interesting to work in the medical field helping my Native people. In time, an opportunity arose and a life coach position became available. I applied and now am a proud member of the STAR team for a little over 4 and half years. In the process, I have also obtained a certified personal trainer certificate. I get to help my Native brothers and sisters in a rewarding capacity by using my experience and the strength of the curriculum. Through the many acquaintances, I have made some lifelong friendships.”

3.  “I have lost a total of 15 pounds with the Star program. I have increased my activity and I feel amazing as the result. I feel I'm not out of breathe anymore when doing cardio. I am an active runner and with all the pounds being taken away my legs don't hurt like they use to when running last spring. I have also seen results as my pull ups are looking a lot better than they ever have because I am down 15 pounds from what I had started with. The benefits are incredible. I get compliments from so many people wondering what I am doing. This program does not make me feel like it is a diet but a true lifestyle change. This class has truly helped me with my diet completely. This class has helped me learn about proteins and I don't have to get it from chicken. My recipes and lunches have been so much more creative because of this class and I am so thankful it has brought me to this place of being healthy and happy. I love how the program is setup because it’s in baby steps and the staff has been amazing because when I would slip, they got me back on track so now it’s just a habit to stay on the healthy lifestyle.”

4.  “STAR cooking and Get SET has helped me out a lot. It has motivated me to come into the clinic and exercise. STAR cooking has taught me how to cook properly for my health and to stay on the right diet plan to continue my health management. The reason I come to STAR cooking is because I have high blood pressure, which caused my kidneys to fail. The diet plan for diabetics is similar for what I need to do on my diet plan with my health issues. I’m a 74-year-old woman and this helps me to keep healthy.”

5.  BL has managed to lose 20 pounds since she began the STAR program. By the end of the initial 8 weeks, she managed to lose 12 pounds:

Prior to my participation in the STAR Program I felt that I would be unable to make significant changes to my weight and to my overall health. I have tried other methods and programs that were not effective. The life coaches celebrated even the smallest improvements and gave me different options to overcome obstacles as well. The STAR program has equipped me with tools and resources so that I can make informed changes that will result in a healthier future.”

v A complete testimony from Ms. Sunday-Allen on behalf of OKCIC is attached to NCUIH’s testimony.